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Chest Pain

By

Andrea D. Thompson

, MD, PhD, University of Michigan;


Michael J. Shea

, MD, Michigan Medicine at the University of Michigan

Last full review/revision Sep 2020| Content last modified Sep 2020
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Chest pain is a very common complaint. Many patients are well aware that it is a warning of potential life-threatening disorders and seek evaluation for minimal symptoms. Other patients, including many with serious disease, minimize or ignore its warnings. Pain perception (both character and severity) varies greatly between individuals as well as between men and women. However described, chest pain should never be dismissed without an explanation of its cause.

Pathophysiology of Chest Pain

The heart, lungs, esophagus, and great vessels provide afferent visceral input through the same thoracic autonomic ganglia. A painful stimulus in these organs is typically perceived as originating in the chest, but because afferent nerve fibers overlap in the dorsal ganglia, thoracic pain may be felt (as referred pain) anywhere between the umbilicus and the ear, including the upper extremities.

Painful stimuli from thoracic organs can cause discomfort described as pressure, tearing, gas with the urge to eructate, indigestion, burning or aching. Uncommonly, other descriptions of chest pain are given such as stabbing or sharp needle-like pain. When the sensation is visceral in origin, many patients deny they are having pain and insist it is merely “discomfort.”

Etiology of Chest Pain

Many disorders cause chest pain or discomfort. These disorders may involve the cardiovascular, gastrointestinal, pulmonary, neurologic, or musculoskeletal systems (see table Some Causes of Chest Pain Some Causes of Chest Pain Chest pain is a very common complaint. Many patients are well aware that it is a warning of potential life-threatening disorders and seek evaluation for minimal symptoms. Other patients, including... read more ).

Some disorders are immediately life threatening:

Other causes range from serious, potential threats to life to causes that are simply uncomfortable. Often no cause can be confirmed even after full evaluation.

Overall, the most common causes are

In some cases, no etiology of the chest pain can be determined.

Table
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Evaluation of Chest Pain

History

History of present illness should note the location, duration, character, and quality of the pain. The patient should be asked about any precipitating events (eg, straining or overuse of chest muscles), as well as any triggering and relieving factors. Specific factors to note include whether pain is present during exertion or at rest, presence of psychologic stress, whether pain occurs during respiration or coughing, difficulty swallowing, relationship to meals, and positions that relieve or exacerbate pain (eg, lying flat, leaning forward). Previous similar episodes and their circumstances should be noted with attention to the similarity or lack thereof and whether the episodes are increasing in frequency and/or duration. Important associated symptoms to seek include dyspnea Dyspnea Dyspnea is unpleasant or uncomfortable breathing. It is experienced and described differently by patients depending on the cause. Although dyspnea is a relatively common problem, the pathophysiology... read more , palpitations, syncope, diaphoresis, nausea or vomiting, cough, fever, and chills.

Review of systems should seek symptoms of possible causes, including leg pain, swelling, or both (deep venous thrombosis Deep Venous Thrombosis (DVT) Deep venous thrombosis (DVT) is clotting of blood in a deep vein of an extremity (usually calf or thigh) or the pelvis. DVT is the primary cause of pulmonary embolism. DVT results from conditions... read more Deep Venous Thrombosis (DVT) [DVT] and therefore possible pulmonary embolism) and chronic weakness, malaise, and weight loss (cancer).

Past medical history should document known causes, particularly cardiovascular and gastrointestinal (GI) disorders, and any cardiac investigations or procedures (eg, stress testing, catheterization). Risk factors for coronary artery disease (CAD—eg, hypertension, dyslipidemia, diabetes, cerebrovascular disease, tobacco use) or pulmonary embolism (eg, lower extremity injury, recent surgery, immobilization, known cancer, pregnancy) should also be noted.

Drug history should note use of drugs that can trigger coronary artery spasm (eg, cocaine, triptans) or GI disease (particularly alcohol, nonsteroidal anti-inflammatory drugs).

Family history should note history of myocardial infarction (particularly among 1st-degree relatives at an early age, ie, < 55 in men and < 60 in women) and hyperlipidemia.

Physical examination

Vital signs and weight are measured, and body mass index (BMI) is calculated. Pulses are palpated in both arms and both legs, blood pressure is measured in both arms, and pulsus paradoxus Pulsus paradoxus Complete examination of all systems is essential to detect peripheral and systemic effects of cardiac disorders and evidence of noncardiac disorders that might affect the heart. Examination... read more Pulsus paradoxus is measured.

General appearance is noted (eg, pallor, diaphoresis, cyanosis, anxiety).

Neck is inspected for venous distention and hepatojugular reflux, and the venous wave forms are noted. The neck is palpated for carotid pulses, lymphadenopathy, or thyroid abnormality. The carotid arteries are auscultated for bruit.

Lungs are percussed and auscultated for presence and symmetry of breath sounds Auscultation Key components in the evaluation of patients with pulmonary symptoms are the history, physical examination, and, in many cases, a chest x-ray. These components establish the need for subsequent... read more Auscultation , signs of congestion (dry or wet crackles, rhonchi), consolidation (pectoriloquy), pleural friction rubs, and effusion (decreased breath sounds, dullness to percussion).

The cardiac examination notes the intensity and timing of the 1st heart sound (S1) and 2nd heart sound (S2), the respiratory movement of the pulmonic component of S2, pericardial friction rubs, murmurs, and gallops. When murmurs are detected, the timing, duration, pitch, shape, and intensity and the response to changes of position, handgrip, and the Valsalva maneuver should be noted. When gallops are detected, differentiation should be made between the 4th heart sound (S4), which is often present with diastolic dysfunction or myocardial ischemia, and the 3rd heart sound (S3), which is present with systolic dysfunction.

The chest is inspected for skin lesions of trauma or herpes zoster infection and palpated for crepitance (suggesting subcutaneous air) and tenderness. The abdomen is palpated for tenderness, organomegaly, and masses or tenderness, particularly in the epigastric and right upper quadrant regions.

The legs are examined for arterial pulses, adequacy of perfusion, edema, varicose veins, and signs of DVT (eg, swelling, erythema, tenderness).

Red flags

Certain findings raise suspicion of a more serious etiology of chest pain:

  • Abnormal vital signs (tachycardia, bradycardia, tachypnea, hypotension)

  • Signs of hypoperfusion (eg, confusion, ashen color, diaphoresis)

  • Shortness of breath

  • Hypoxemia on pulse oximetry

  • Asymmetric breath sounds or pulses

  • New heart murmurs

  • Pulsus paradoxus > 10 mm Hg

Interpretation of findings

Symptoms and signs of thoracic disorders vary greatly, and those of serious and nonserious conditions often overlap. Although red flag findings indicate a high likelihood of serious disease, and many disorders have “classic” manifestations (see table Some Causes of Chest Pain Some Causes of Chest Pain Chest pain is a very common complaint. Many patients are well aware that it is a warning of potential life-threatening disorders and seek evaluation for minimal symptoms. Other patients, including... read more ), many patients who have serious illness do not present with these classic symptoms and signs. For example, patients with myocardial ischemia may complain only of indigestion or have a very tender chest wall on palpation. A high index of suspicion is important when evaluating patients with chest pain. Nonetheless, some distinctions and generalizations are possible.

Duration of pain can provide clues to the severity of the disorder. Long-standing pain (ie, for weeks or months) is not a manifestation of a disorder that is immediately life threatening. Such pain is often musculoskeletal in origin, although gastrointestinal origin or a cancer should be considered, particularly in patients who are older. Similarly, brief (< 5 seconds), sharp, intermittent pains rarely result from serious disorders. Serious disorders typically manifest pain lasting minutes to hours, although episodes may be recurrent (eg, unstable angina may cause several bouts of pain over 1 or more days).

Patient age is helpful in evaluating chest pain. Chest pain in children and young adults (< 30 years) is less likely to result from myocardial ischemia, although myocardial infarction can occur in people in their 20s. Musculoskeletal and pulmonary disorders are more common causes in these age groups.

Exacerbation and relief of symptoms also are helpful in evaluating chest pain. Although angina can be felt anywhere between the ear and the umbilicus, it is typically consistently related to physical or emotional stress, ie, patients do not experience angina from climbing one flight of stairs one day and tolerate 3 flights the next day. Nocturnal angina is characteristic of acute coronary syndromes, heart failure, or coronary artery spasm.

Pain from many disorders, both serious and minor, can be exacerbated by respiration, movement, or palpation of the chest. These findings are not specific for origin in the chest wall; about 15% of patients with acute myocardial infarction have chest tenderness on palpation.

Nitroglycerin may relieve pain of both myocardial ischemia and noncardiac smooth muscle spasm (eg, esophageal or biliary disorders); its efficacy or lack thereof should not be used for diagnosis.

Associated findings may also suggest a cause. Fever is nonspecific but, if accompanied by cough, suggests a pulmonary cause. Patients with Raynaud syndrome Raynaud Syndrome Raynaud syndrome is vasospasm of parts of the hand in response to cold or emotional stress, causing reversible discomfort and color changes (pallor, cyanosis, erythema, or a combination) in... read more Raynaud Syndrome or migraine headaches sometimes have coronary spasm.

The presence or absence of risk factors for CAD Risk Factors Coronary artery disease (CAD) involves impairment of blood flow through the coronary arteries, most commonly by atheromas. Clinical presentations include silent ischemia, angina pectoris, acute... read more Risk Factors (eg, hypertension Hypertension Hypertension is sustained elevation of resting systolic blood pressure (≥ 130 mm Hg), diastolic blood pressure (≥ 80 mm Hg), or both. Hypertension with no known cause (primary; formerly, essential... read more Hypertension , hypercholesterolemia Dyslipidemia Dyslipidemia is elevation of plasma cholesterol, triglycerides (TGs), or both, or a low high-density lipoprotein cholesterol level that contributes to the development of atherosclerosis. Causes... read more Dyslipidemia , smoking, obesity Obesity Obesity is excess body weight, defined as a body mass index (BMI) of ≥ 30 kg/m2. Complications include cardiovascular disorders (particularly in people with excess abdominal fat), diabetes mellitus... read more , diabetes Diabetes Mellitus (DM) Diabetes mellitus is impaired insulin secretion and variable degrees of peripheral insulin resistance leading to hyperglycemia. Early symptoms are related to hyperglycemia and include polydipsia... read more , positive family history) alters the probability of underlying CAD but does not help diagnose the cause of a given episode of acute chest pain. Patients with those factors may well have another cause of chest pain, and patients without them may have an acute coronary syndrome Overview of Acute Coronary Syndromes (ACS) Acute coronary syndromes result from acute obstruction of a coronary artery. Consequences depend on degree and location of obstruction and range from unstable angina to non–ST-segment elevation... read more . However, known CAD in a patient with chest pain raises the likelihood of that diagnosis as the cause (particularly if the patient describes the symptoms as “like my angina” or “like my last heart attack”). A history of peripheral vascular disease Peripheral Arterial Disease Peripheral arterial disease (PAD) is atherosclerosis of the extremities (virtually always lower) causing ischemia. Mild PAD may be asymptomatic or cause intermittent claudication; severe PAD... read more Peripheral Arterial Disease also raises the likelihood that angina is the cause of chest pain.

Testing

For adults with acute chest pain, immediate life threats must be ruled out. Most patients should initially have pulse oximetry, ECG Electrocardiography The standard electrocardiogram (ECG) provides 12 different vector views of the heart’s electrical activity as reflected by electrical potential differences between positive and negative electrodes... read more , and chest x-ray. In patients with hemodynamic instability, a bedside echocardiogram can also be useful in further evaluating potential life-threatening causes.

If symptoms suggest an acute coronary syndrome Overview of Acute Coronary Syndromes (ACS) Acute coronary syndromes result from acute obstruction of a coronary artery. Consequences depend on degree and location of obstruction and range from unstable angina to non–ST-segment elevation... read more or if no other cause is clear (particularly in at-risk patients), troponin levels Cardiac markers Acute coronary syndromes result from acute obstruction of a coronary artery. Consequences depend on degree and location of obstruction and range from unstable angina to non–ST-segment elevation... read more are measured. Expeditious evaluation is essential because if myocardial infarction or other acute coronary syndrome is present, the patient should be considered for urgent heart catheterization (when available). Immediate catheterization is indicated in patients with ST-elevation on ECG, non–ST-segment elevation myocardial infarction (NSTEMI) causing hypotension, ventricular arrhythmias, or persistent chest pain despite optimal medical management.

Some abnormal findings on these tests confirm a diagnosis (eg, acute myocardial infarction Acute Myocardial Infarction (MI) Acute myocardial infarction is myocardial necrosis resulting from acute obstruction of a coronary artery. Symptoms include chest discomfort with or without dyspnea, nausea, and diaphoresis.... read more Acute Myocardial Infarction (MI) , pneumothorax Pneumothorax Pneumothorax is air in the pleural space causing partial or complete lung collapse. Pneumothorax can occur spontaneously or result from trauma or medical procedures. Diagnosis is based on clinical... read more Pneumothorax , pneumonia Overview of Pneumonia Pneumonia is acute inflammation of the lungs caused by infection. Initial diagnosis is usually based on chest x-ray and clinical findings. Causes, symptoms, treatment, preventive measures, and... read more ). Other abnormalities suggest a diagnosis or at least the need to pursue further investigation (eg, abnormal aortic contour on chest x-ray suggests need for testing for thoracic aortic dissection Aortic Dissection Aortic dissection is the surging of blood through a tear in the aortic intima with separation of the intima and media and creation of a false lumen (channel). The intimal tear may be a primary... read more Aortic Dissection ). Thus, if these initial test results are normal, thoracic aortic dissection, tension pneumothorax, and esophageal rupture are highly unlikely. However, in acute coronary syndromes, ECG may not change for several hours or sometimes not at all, and in PE, oxygenation may be normal. Thus, other studies may need to be obtained based on findings from the history and physical examination (see table Some Causes of Chest Pain Some Causes of Chest Pain Chest pain is a very common complaint. Many patients are well aware that it is a warning of potential life-threatening disorders and seek evaluation for minimal symptoms. Other patients, including... read more ).

Because a single normal set of cardiac markers does not rule out a cardiac cause, patients whose symptoms suggest an acute coronary syndrome should have serial measurement of the cardiac marker troponin and ECGs at least 4 hours apart. Drug treatment for suspected acute coronary syndrome Drugs for Acute Coronary Syndromes Treatment of acute coronary syndromes (ACS) is designed to relieve distress, interrupt thrombosis, reverse ischemia, limit infarct size, reduce cardiac workload, and prevent and treat complications... read more is begun while awaiting results of the 2nd troponin level unless there is a clear contraindication. A diagnostic trial of sublingual nitroglycerin or an oral liquid antacid does not adequately differentiate myocardial ischemia from gastroesophageal reflux disease or gastritis. Either drug may relieve symptoms of either disorder.

Troponin will be elevated in all acute coronary syndromes causing cardiac injury and often in other disorders that damage the myocardium (eg, myocarditis Myocarditis Myocarditis is inflammation of the myocardium with necrosis of cardiac myocytes. Myocarditis may be caused by many disorders (eg, infection, cardiotoxins, drugs, and systemic disorders such... read more Myocarditis , pericarditis Pericarditis Pericarditis is inflammation of the pericardium, often with fluid accumulation. Pericarditis may be caused by many disorders (eg, infection, myocardial infarction, trauma, tumors, metabolic... read more Pericarditis , aortic dissection Aortic Dissection Aortic dissection is the surging of blood through a tear in the aortic intima with separation of the intima and media and creation of a false lumen (channel). The intimal tear may be a primary... read more Aortic Dissection involving coronary artery flow, pulmonary embolism, heart failure, severe sepsis). Creatine kinase (CK) may be elevated due to damage to any muscle tissue, but creatine kinase-MB isoenzyme (CK-MB) elevation is specific to damage to the myocardium. However, troponin is now the standard marker of cardiac muscle injury. Advances in high-sensitivity troponin assays may allow for more rapid serial evaluation of a possible acute coronary syndrome. With improved negative predictive value, high sensitivity troponin also has the potential to decrease the necessity of further testing in patients with negative biomarkers and has been demonstrated to allow patients to be discharged more quickly (1 Diagnosis reference Chest pain is a very common complaint. Many patients are well aware that it is a warning of potential life-threatening disorders and seek evaluation for minimal symptoms. Other patients, including... read more ). ST-segment abnormality on the ECG may be nonspecific or due to antecedent disorders, so comparison with previous ECGs is important. Some clinicians follow initial testing (acutely or within several days) with a stress ECG or a stress imaging test.

If a pulmonary embolism (PE) is considered possible, D-dimer testing is done in low- and intermediate-risk patients. The likelihood of pulmonary embolism is affected by a number of clinical factors, which can be used to derive an approach to testing. Many of these factors are included in scoring systems that help determine the probability of PE such as the Modified Wells Scoring System, the Revised Geneva Scoring System, and the Pulmonary Embolism Rule Out Criteria (PERC).

In patients with chronic chest pain, immediate threats to life are unlikely. Most clinicians initially obtain a chest x-ray and do other tests based on symptoms and signs.

Diagnosis reference

Treatment of Chest Pain

Specific identified disorders are treated. If etiology is not clearly benign, patients are usually admitted to the hospital or an observation unit for cardiac monitoring and more extensive evaluation. Pain Overview of Pain Pain is the most common reason patients seek medical care. Pain has sensory and emotional components and is often classified as acute or chronic. Acute pain is frequently associated with anxiety... read more is treated with acetaminophen or opioids as needed, pending a diagnosis. Pain relief following opioid treatment should not diminish the urgency of ruling out serious and life-threatening disease.

Geriatrics Essentials

The probability of serious and life-threatening disease increases with age. Many older patients recover more slowly than younger patients but survive for significant time if properly diagnosed and treated. Drug doses are usually lower, and rapidity of dose escalation is slower. Chronic disorders (eg, chronic kidney disease) are often present and may complicate diagnosis and treatment.

Key Points

  • Immediate life threats must be ruled out first.

  • Some serious disorders, particularly coronary ischemia and pulmonary embolism, often do not have a classic presentation.

  • Most patients should have pulse oximetry, ECG, cardiac marker measurement, and chest x-ray.

  • Evaluation must be prompt so that patients with ST-elevation myocardial infarction or other criteria for intervention can be in the heart catheterization laboratory (or have thrombolysis) within the 90-minute standard.

  • If PE is highly likely, antithrombin drugs should be given while the diagnosis is pursued; another embolus in a patient who is not receiving anticoagulants may be fatal.

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